information is power and having it at the right time can ...new...taxpayers network inc. through...

TA X PA Y E R S N E T W O R K I N C .

THROUGH KNOWLEDGE COMES VALUE

Information is power and having it at the right time can

mean significant savings for you. TNI is an association

devoted to ensuring you have the information you need to

make the best choices for your life and your pocketbook.

TAXPAYERS NETWORKW67 N222 Evergreen Blvd. #202

Cedarburg, WI 53012-2645Phone: (920) 662-1492

Fax: (920) 662-1517www.TaxpayersNetwork.org TNI 8/05 GN1659

TAXPAYERS NETWORK INC.

MEANS VALUE

TNI began in 1992 as Taxpayers Network Inc. Currently an Ohio-based nonprofit association, this company arose from the desire tomake it easier for the American consumer to receive informationabout taxpayer dollars and how to get the best deal for his or herincome.

This association has grown into a network of individuals and small business owners across the nation—a network ofinformed, prepared consumers who are realizing significant value for their money.

MAKES THE MOST FOR YOUR MONEY!

As a dues-paying member, you will receive a TNI quarterlynewsletter that provides tips for small businesses and individualsto manage their money more wisely. Your spouse and minorchildren are also entitled to all the benefits of your membership.

A TNI membership allows you to relax, knowing your association is working hard to maximize your consumer dollars.

Don’t let another minute go by without realizing the savings and information TNI can bring you or your company.Become a TNI member today! For more information about amembership, call us today at (920) 662-1492.

ASSOCIATION BENEFITS

Dental Discounts• Receive discounted fees for preventive services. All other services, save 15%.

Chiropractic Discounts• Free consultation! 30-50% savings on all other services.

Access to Health Insurance• Available in selected states.

Hearing service discounts• Save up to 60% on hearing aids.

Vitamin Discounts Catalog• Save up to 50% on more than 4,500 health products, including Enzymatic

Therapy products.

Home Medical Equipment• Receive access to thousands of products.

MEDICARD Emergency Medical Information Card• Receive a card with microfiche containing your medical and prescription records.

Motorclub Discount Emergency Roadside Assistance• Obtain emergency assistance 24 hours a day, 365 days a year.

Car Rental With Discounts At Avis, Hertz, Alamo, and National.

PowerNet Global Communications• 4.9¢ a minute long distance with no monthly fee.

Pre-employment Background Reports and Investigative Services Discounts• Members use this service for their personnel needs.

Vision Discounts• Save 20 - 60% on eyeglasses and other retail eyewear from 10,000 vision

professionals nationwide and on contact lenses ordered by mail.

Save 10 - 30% on eye exams and surgical procedures from ophthalmologists.

Alternative Medicine Plan• For only $24.95 a year, receive access to deep discounts at more than 9,000

providers of complementary and alternative medicine for you and your household members.

Global Frontiers, Inc.• Receive unlimited dial-up access to the Internet for $14.95 a month. Includes

unlimited e-mail, nationwide access, and more than 36,000 news groups.

TA X PA Y E R S N E T W O R K I N C .

THROUGH KNOWLEDGE COMES VALUE

Information is power and having it at the right time can

mean significant savings for you. TNI is an association

devoted to ensuring you have the information you need to

make the best choices for your life and your pocketbook.

TAXPAYERS NETWORKW67 N222 Evergreen Blvd. #202

Cedarburg, WI 53012-2645Phone: (920) 662-1492

Fax: (920) 662-1517www.TaxpayersNetwork.org TNI 8/05 GN1659

MedOne®

A selection of health insurance plans for Individuals & Families

Florida

Page 1 of 24

of 24

Expertise — Choice — Customer Focus.What you want from your health insurance company.

ExpertiseAt American Medical Security from PacifiCare (AMS), health plans for individuals and families are

what we do best. Over the years, we’ve used our expertise to design plans that give you more

choices, more options, and more ways to get the most from your premium dollar.

ChoiceWe place an emphasis on choice — your choice. Our wide selection of health insurance products

for individuals allows you to develop a plan that’s based on your health and economic

requirements. Plus, you can enhance your coverage to meet your health needs by selecting

prescription drug coverage or dental insurance.

Customer FocusFrom questions about a claim to verifying providers, we’ll get you the answers when you need

them. With our 24-hour customer service, we’re there to take your call, whether it’s one in

the afternoon or three in the morning. And you’ll always talk to a friendly customer service

representative — without a menu of buttons to push.

Because we value your health, you’ll have access to resources so you can get the most from your

health plan. Whether you need to speak to a registered nurse, research hospitals, participate in

an online wellness program, or order prescriptions online; we give you the tools to put

knowledge at your fingertips.

Expertise — Choice — Customer Focus. What you’ll receive from American Medical Security.

Contents

Plan Designs 3

Value-Added Services 4

Insurance Plan Features 5

MedOne Plus 6

MedOne Security 8

MedOne HSAvings 10

Optional Benefits 14

Covered Expenses 16

State Coverages 17

Plan Provisions 19

MedOneA selection of health insurance plans for Individuals & Families

Med

One

Plus

®M

edO

neSe

curi

ty®

Med

One

HSA

ving

sSM

Deductible:

The amount of covered

expenses you pay each

calendar year before benefits

are paid under the Policy.

Preferred ProviderOrganization (PPO):

A group of health-care

providers contracted to

provide medical services at

negotiated rates.

Copayment (Copay):

A fixed fee that you pay

toward charges.

Coinsurance:

The insurance plan’s level of

coverage after the calendar-

year deductible is satisf ied.

After the coinsurance limit is

met, the insurer pays 100%

of covered expenses for

the remainder of the

calendar year.

With AMS, the choice is yours. You can choose from the lower out-of-pocketcosts of a traditional health insurance plan to the lower premium of a high-deductible plan. Ormaybe it’s the tax savings possible from a health savings account (HSA) paired with an insurance planthat you’re looking for — the choice is yours.

Below you’ll find a brief overview of our three plan designs.

Page 3 of 24

MedOne Plus®

MedOne Plus, AMS’ premier product, provides you the valueof a traditional health insurance plan that uses a preferredprovider organization (PPO). This plan design features:

• Lower deductibles and out-of-pocket costs.

• Coverage with only one copayment for most office visits and preventive services.

• A wide range of copayments, deductibles, and coinsurance amounts to fit your health-care needs.

Mary has two small children who make

frequent visits to the doctor’s off ice.

She prefers the single copay and

the lower out-of-pocket costs of

MedOne Plus.

MedOne Security®

MedOne Security can be a cost-effective product if you prefer insurance for major medical expenses. This plan design features:

• A wide range of premium-saving higher deductibles andfacility copayments to choose from.

• Coverage for emergencies and major illness.Jim, a recent college graduate, rarely

visits the doctor’s off ice but wants to be

sure he has coverage should he have an

accident or serious illness. He’s decided

that MedOne Security is for him.

MedOne HSAvingsSM

MedOne HSAvings paired with an HSA is ideal if you’d likegreater control of your health-care dollars with potential taxsavings. This plan design features:

• A lower premium with a high-deductible.

• An aggregate deductible where a family’s eligible expenses are pooled together to meet one deductible.

Fred and Michelle like their money

to work for them, so they choose MedOne

HSAvings. They prefer a higher

deductible plan and like the possibility

of tax savings when paired with a

health savings account.

Eligibility

If you’d like to apply for a MedOne health insurance plan, you must be a member in good standingof the Taxpayers Network Inc. (TNI) Association, age 18 or over and under age 65. All applicants mustmeet the insurer's underwriting requirements and be U.S. citizens or be in the U.S. by a permanentresident card. A copy of the permanent resident card (form I-551) is required. Your dependents whowish to have coverage must be a lawful spouse and/or unmarried child under age 19. If the child isa full-time student at an accredited school, college, or university, coverage is provided to age 25.

EarlyCare Coverage (child only)

When you need to purchase coverage for a child only, choose MedOne Security or MedOne Plus plansEarlyCare option. EarlyCare coverage is ideal for providing child protection as an alternative toemployer-sponsored coverage, when a divorce decrees child coverage is mandatory, or for grandparentswho want to ensure grandchildren have coverage. Parents or legal guardians can apply for coveragefor eligible children. Eligible applicants include unmarried children age 14 days to 19 years or to age25 if the child is a full-time student at an accredited school, college, or university. Parents or legalguardians must also be members in good standing of the TNI Association.

Testing Requirement

Specimen testing is required for all primary applicants age 18 through 59. Upon receipt of anapplication, a licensed paramedical examiner may contact you to coordinate an appointment that isconvenient for you. The specimen will be tested for HIV, drugs of abuse, and tobacco use.

Value-Added Services and Discounts

These noninsurance services are provided through a contractual agreement with third parties, andare not administered or underwritten by us. Unless indicated, these services are available to most AMScustomers.

24–Hour Customer ServiceWhenever you call AMS, a customer service representative will answer the phone — 24 hours a day,365 days a year. You can expect prompt, friendly service and accurate information about claims, general coverage, and benefits any time of the day or night.

24–hour Nurse Line and Audio Library*From rashes to headaches, allergies to stomach pain, the 24-hour information program is a greatsource of general health information to supplement your physician’s care. Simply call the 24-hourNurse Line toll free at any time to speak with an experienced, registered nurse about your healthconcerns. You also have the option of listening to prerecorded information on many health topics inthe Audio Library.

AMS Health Discovery CenterSM*The AMS Health Discovery Center may help you control the quality and costs of your health care. It’san interactive online resource that contains extensive information about medical conditions andtreatments, prescription and over-the-counter drugs and their costs, hospital rankings, questions toask your doctor, and more.

* The 24-hour Health Information Program is offered by PacifiCare Health Plan Administrators, Inc. It’s intentand the intent of the AMS Health Discovery Center is to provide general information regarding common healthquestions or conditions. If you have a specific question relating to a condition or medical course of treatmentfor yourself or others, please consult your physician. If you believe you need emergency room services, call 911,or its local equivalent, or go to the nearest medical facility for treatment.

EarlyCare coverage is ideal

for providing child protection

as an alternative to employer

-sponsored coverage, or for

grandparents who want to

ensure grandchildren have

coverage.

Customer service represen-

tatives are available to

answer the phone — 24

hours a day, 365 days a year.

Page 4 of 24

Plan Information

PPO Plan OptionsWith all MedOne insurance plans, you have the freedom to visit the doctor you feel most comfortablewith — the doctor you trust. You can save money by selecting a PPO insurance plan and visiting networkproviders when you need treatment.

Prescription DiscountWhen you purchase your prescription drugs at a member pharmacy, you pay the entire cost of yourprescription drug but at the discounted cost. (See pages 7, 9, and 14 for coverage options.)

Dental DiscountsAMS and CAREINGTON International have an agreement to provide MedOne insureds with a dentaldiscount program. Thousands of participating dentists nationwide present discounts on a variety of common dental services — from cleanings and exams to crowns and prosthetics. Dentalinsurance with broad coverage is available to replace the CAREINGTON discount program. (See page 15 for more information.)

VSP® DiscountsLaser Vision Discounts: VSP has made arrangements with laser surgery facilities and doctors to offerits members discounts that average 20% to 25%. Eyewear Discounts: VSP doctors offer valuable savings, including a 20% discount on pairs of prescription glasses (lenses and frame) not covered byan eyewear benefit. You can also save 15% on the cost of your contact lens exam when you receivecontact lens services from VSP.

Insurance Plan Features

Unless indicated, these plan features are included with all MedOne plan designs.

TravelCare®The TravelCare benefit allows insureds who are traveling outside their networks’ primary serviceareas to receive care from a nationwide PPO network. Receive care from a nationwide provider and get network-level coverage that may mean less out-of-pocket expense for you. To receive thisinsurance benefit, select an insurance plan design using a PPO.

On-the-Job ProtectionOn-the-Job Protection offers 24-hour coverage for eligible medical expenses due to work-relatedinjury or sickness.

Non-tobacco Use DiscountIf you don’t use tobacco, you may receive premium savings.

Get the most from your plan!When you precertify treatment, health-care management professionals can advise you and yourphysician of the coverage available for your treatment. By offering sensible, cost-effective solutions,we encourage you to manage your health care and get the most from your insurance plan.

PPO NetworksA network of credentialed doctors, clinics, hospitals, and other health-care providers are contractedto provide medical services at negotiated fees. Your benefits may be greater when you select a PPOnetwork and use network providers. Network providers are compensated for services covered underthe Policy at predetermined rates which are usually less than the provider’s customary rates.Network provider charges for covered services are considered reasonable and customary. AMS mayreplace the network at any time. You’ll receive advance notice of changes.

Receive up to $1,000 CashIf you find an overcharge on a hospital or medical bill, we may pay you up to 50% of the savings, upto $1,000 cash per calendar year.

Page 5 of 24

MedOne Plus

Page 6 of 24

Features PPO Benefit Plan 100% PPO Benefit PlanLifetime MaximumPer insured $5 Million $5 Million

Office Visit Copay OptionsA fixed fee that you pay toward office visit charges. $30 $30When no copay (none) is selected, charges for the office visit $40 $40are payable after your selected deductible and coinsurance. None None

Deductible OptionsThe amount of covered expenses you pay each calendar year Network Non-network Network Non-networkbefore benefits are paid under the insurance Policy. $ 1,000 $ 2,000 $ 500 $ 1,000

$ 1,500 $ 3,000 $ 750 $ 1,500

$ 2,500 $ 5,000 $ 1,000 $ 2,000

$ 5,000 $ 10,000 $ 1,500 $ 3,000

$ 7,500* $ 15,000 $ 2,500 $ 5,000

$ 10,000* $ 20,000 $ 5,000 $10,000

* Not available with $30 copay

Coinsurance OptionsThe level of coverage for eligible expenses provided by the 100% 70% 80% 50%insurance plan after the calendar year deductible is satisfied. 50%* 50%

* Not available with all networks.

Individual Out-of-Pocket MaximumThe maximum amount you pay per calendar year for covered expenses, $0 $4,000 $ 2,000** $ 4,000plus your selected deductible. $ 4,000*** $ 8,000

*** Only available with 80% option.*** Only available with 50% option.

XL OptionThis option pays 100% to $150 per covered person, per calendar year PPO Benefit Plan PPO Benefit Planfor Network routine and non-routine x-rays and laboratory tests. 100% XL Option XL OptionSee page 14 for complete details.

Insurance plans provide only limited benefits for services provided by non-network providers. Benefits received from non-network providers are subject to a separate non-network deductible and coinsurance limit.

Note: The Classic Benefit plan (Non-PPO) is available.

Choosing a MedOne Plus Plan Design

MedOne Plus provides you the value of a traditional health insurance plan that uses a preferred provider organization.

1. Carefully review both of the MedOne Plus plan designs listed below. Choose either the PPO Benefit Plan 100% or thePPO Benefit Plan.

2. After you select your plan design, choose an office visit copay and network deductible amount.

3. If you select the PPO Benefit Plan, you’ll also need to choose your network coinsurance amount (either 80% or 50%).

4. When an office visit copay is selected, both plan designs allow you to select the X-ray and Lab Option (XL), whichwill upgrade your selection to a PPO Benefit Plan 100% XL Option or PPO Benefit Plan XL. If you anticipate medicalimaging or lab procedures, this option may be worth considering. See description on page 14.

5. Select optional benefits such as dental insurance and prescription drug coverage to enhance your plan. See page 14 and 15 for more information.

Med

One

Plus

®

MedOne Plus

Page 7 of 24

The Following Coverage Applies to 100%, 80%, and 50% OptionsPhysician Office Visit

Network Office Visit Non-network Office VisitCopay then 100% Deductible, coinsurance, then 100%

When no copay (none) is selected, charges for the office visit are payable after your selected deductible then coinsurance, then 100%.

Wellness BenefitNetwork Office Visit Non-network Office Visit Network X-ray/lab Non-network X-ray/labCopay then 100% Not Covered (PSA, Pap smear, and

mammogram)Deductible, coinsurance, Not Coveredthen 100%

When no copay (none) is selected, charges for the office visit are payable after your selected deductible, coinsurance, then 100%.

Radiology (X-ray) Test/Pathology (lab) TestDeductible, coinsurance, then 100%

If the XL buy-up option is selected, see page 6 for coverage details.

Surgery and Anesthesiology FeeDeductible, coinsurance, then 100%

Routine Vision ExamVision Benefit Network Provider Vision Benefit Non-network Provider$10 copay, then 100% Payable to a maximum of $38 after $10 copay

Inpatient and Outpatient Facility ChargesDeductible, coinsurance, then 100%

Physician Inpatient Hospital VisitDeductible, coinsurance, then 100%

Emergency Room Charges $100 copay, deductible, coinsurance, then 100%

Copay is waived if immediately confined.

Ambulance (air and ground)Deductible, coinsurance, then 100%

Prescription DrugDrug discount program

Drug discount program is not an insurance benefit.

Prescription Drug Coverage Options

Choose from these deductibles; $0, $500 or $1,000, then the following coverage applies:

Retail Mail Order

Generic drug Brand name Generic drug Brand name$15 copay; 50% coinsurance; $30 copay; $60 copay;30-day supply 30-day supply 90-day supply 90-day supply

When generic is available and you choose brand, you pay the difference between the two. If selected, separate prescription drug deductibles andcoinsurance levels are per person, per calendar year.



of 24

MedOne Security



P P O F a c i l i t y C o p a y P l a nFeatures 100% Option 80% Option 50% OptionLifetime MaximumPer insured $5 Million $5 Million $5 Million

Office Visit Copay OptionsA fixed fee that you pay toward $40 $30 $30office visit charges. When no copay (none) None $40 $40is selected, charges for the office visit are None None

payable after your selected deductible and coinsurance.

Deductible OptionsThe amount of covered expenses you Network Non-network Network Non-network Network Non-networkpay each calendar year before benefits $ 5,000 $10,000 $ 1,000 $ 2,000 $ 1,000 $ 2,000are paid under the insurance Policy.

$ 7,500 $15,000 $ 1,500 $ 3,000 $ 1,500 $ 3,000

$10,000 $20,000 $ 2,000 $ 4,000 $ 2,000 $ 4,000

$ 4,000 $ 8,000 $ 4,000 $ 8,000

$ 5,000* $10,000 $ 5,000* $10,000

$ 7,500* $15,000 $ 7,500* $15,000

$10,000* $20,000 $10,000* $20,000

*Not available with $30 copay *Not available with $30 copay

Inpatient/Outpatient Facility ChargesThe facility copays apply to both Network $500 inpatient copay and $250 outpatient copay,and Non-network facility charges. deductible, coinsurance, then 100% when choosing deductible options from $1,000-$4,000.

-OR-$1,000 inpatient copay and $500 outpatient copay,deductible, coinsurance, then 100% when choosing deductible options from $5,000-$10,000.

Coinsurance OptionsThe level of coverage for eligible expenses 100% 70% 80% 50% 50% 50%provided by the insurance plan after thecalendar year deductible is satisfied.

Individual Out-of-Pocket MaximumThe maximum amount you pay per $0 $4,000 $2,000 $4,000 $4,000 $8,000calendar year for covered expenses,plus your selected deductible.

Choosing a MedOne Security Plan Design

MedOne Security provides you the coverage for emergencies and major illnesses or injuries while limiting your premiumamount.

1. Carefully review each of the MedOne Security PPO Facility Copay plan designs listed below. Choose either the 100%,80%, or 50% option.

2. After you select your plan design, choose an office visit copay and network deductible amount.

3. Select optional benefits such as dental insurance or prescription drug coverage to enhance your plan. See page 14 &15 for more information.

Med

One

Secu

rity

®

MedOne Security

Page 9 of 24



The Following Coverage Applies to 100%, 80%, and 50% OptionsPhysician Office Visit

Network Office Visit Non-network Office VisitCopay then 100% Deductible, coinsurance, then 100%

When no copay (none) is selected, charges for the office visit are payable after your selected deductible then coinsurance, then 100%.

Wellness BenefitNetwork Office Visit Non-network Office Visit Network X-ray/lab Non-network X-ray/labCopay then 100% Not Covered (PSA, Pap smear, and

mammogram)Deductible, coinsurance, Not Coveredthen 100%

When no copay (none) is selected, charges for the office visit are payable after your selected deductible, coinsurance, then 100%.

Radiology (X-ray) Test/Pathology (lab) TestDeductible, coinsurance, then 100%

Surgery and Anesthesiology FeeDeductible, coinsurance, then 100%

Routine Vision ExamVision Benefit Network Provider Vision Benefit Non-network Provider$10 copay, then 100% Payable to a maximum of $38 after $10 copay

Physician Inpatient Hospital VisitDeductible, coinsurance, then 100%

Emergency Room Charges $100 copay, deductible, coinsurance, then 100%

Copay is waived if immediately confined.

Ambulance (air and ground)Deductible, coinsurance, then 100%

Prescription DrugDrug discount program

Drug discount program is not an insurance benefit.

Prescription Drug Coverage Options

Choose from these deductibles; $0, $500 or $1,000, then the following coverage applies:

Retail Mail Order


When generic is available and you choose brand, you pay the difference between the two. If selected, separate prescription drug deductibles andcoinsurance levels are per person, per calendar year.

An Alternative Approach to Funding Health-Care Costs for Individuals

The cost for health care and health insurance has risen in recent years. As a result, individuals arelooking for solutions. And AMS has a health insurance solution that can help individuals and families.

Many individuals prefer a health insurance plan with lower premiums. They want protection fromfinancial losses that may result from a hospitalization or other catastrophic event but are willing to pay expenses for less serious medical services. Pairing a tax-preferred federal health savingsaccount (HSA)* with a high-deductible health plan (HDHP) may be the answer.

What Is a Health Savings Account (HSA)?An HSA is a federal tax-deductible savings account set up at a financial institution to save moneyexclusively for payment of qualified medical expenses. This account must be used in conjunctionwith a high-deductible health plan that meets government requirements.

What Is a High-Deductible Health Plan (HDHP)?An HDHP has a higher calendar-year deductible than typical health insurance plans and has a maximum limit on the annual out-of-pocket amount for covered expenses. These amounts are determined by the federal government. They follow the Department of Labor’s Consumer Price Indexand may change from year to year.

About HDHPs HDHPs must meet federal guidelines. For 2006, the deductible must be at least $1,050 for individualcoverage and $2,100 for family coverage.

Those with family coverage meet a family deductible, and eligible expenses for all family memberscontribute to that deductible. When the family calendar-year deductible is met by any combinationof family members, the insurance plan pays benefits for the entire family.

HDHPs also have maximum limits on the annual out-of-pocket amounts for covered expenses. The amounts paid to meet the deductible are applied to the maximum out-of-pocket amounts.

MedOne HSAvings*AMS has designed MedOne HSAvings to meet federal government HDHP requirements. The broadselection of available deductibles and coinsurance levels allows you to find a plan design that fitsyour budget needs. Best of all, there are no copays. Optional benefits include routine wellness, dental, and prescription drug buy-ups.

* Both the family and individual deductible plans have been designed to meet the HSA high-deductiblehealth plan requirements of Federal Law (26 U.S.C. Sec. 223). This law contains several requirementsregarding the tax deductibility of HSAs. Please consult with a tax and legal adviser to determine whetherthe HSA will qualify as tax deductible. HSAs are not insurance.

How To Take Advantage of an HSA

1. Obtain a MedOneHSAvings plan.

2. Set up an HSA with afinancial institution.

3. Contribute to the HSA.

4. Use HSA dollars to pay for qualif ied medicalexpenses.

5. Realize tax savings whencomputing taxable incomeon tax returns.

Page 10 of 24

MedOne HSAvings

HDHP’s are underwritten and administered by American Medical Security Life Insurance Company, a wholly ownedsubsidiary of PacifiCare Heath Systems, Inc. HSA's are administered by other financial institutions.

HSA Eligibility

Anyone who has an HDHP

and meets government

requirements may open an

HSA. MedOne HSAvings is

designed by AMS to meet

these requirements.

HSA Tax Advantages

Tax-deductible. Qualif ied

contributions to the HSA

are 100% tax-deductible.

Tax-free. Qualified medical

expense withdrawals are

tax-free. Dollars can be used

to pay for items not usually

covered by health insurance,

such as eyeglasses, dental

care, and much more, as

specif ied by IRS Code

213(d).

Tax-deferred. Accumulated

interest earnings are tax-

deferred. Savings not used

accumulate year after year

and may be used to fund

retirement needs at age 65.

How It Works

Health Plan with an HSAWhen an HSA is used together with an HDHP, health-care expense dollars are split between healthinsurance and the HSA. The HSA owner decides the amount to deposit in the HSA. At the end of theyear, any money that hasn’t been used can remain in the HSA for the following year’s medical expenses.The following diagram illustrates the benefits of an HSA.

Health Plan without an HSAWithout an HSA, health-care expense dollars go entirely to health insurance.

HSA Contributions and WithdrawalsContributions. The amount an individual or family may contribute to the HSA is determined by thefederal government and may change. The 2006 yearly limits are set at the amount equal to the insuranceplan’s deductible or $2,700 for individual coverage and $5,450 for family coverage, whichever is less.

Contributions can be made for any full calendar month provided the HSA owner’s HDHP coveragewas in effect on the first day of that month. Excess contributions, if not withdrawn, may be taxed atthe owner’s current tax rate plus an excise tax of 6%.

Withdrawals. The HSA owner decides where to spend HSA health-care dollars within guidelinesestablished by the federal government. Visits to physician offices, dental care, nursing care, psychiatric care, and chiropractic care are examples of eligible expenses listed in IRS Publication 502,which is available at the IRS Web site, www.irs.gov.

If funds are withdrawn for unqualified expenses, those funds can’t be deducted from taxableincome, and, if the HSA owner is under the age of Medicare eligibility, a 10% penalty may apply.Cosmetic surgery, nutritional supplements, and childcare are examples of unqualified expenses. TheHSA owner is responsible for determining if an expense qualifies according to federal governmentrules and can be paid with HSA funds.

Page 11 of 24

MedOne HSAvings

Med

One

HSA

ving

sSM

Consumer A’s health-care expense dollars

Health insurancepremiums &out-of-pocket expenses

Contributions to ahealth savings account

Money used formedical expenses

Unused money staysin the account forthe following year’smedical expenses.

Consumer B’s health-care expense dollars

Health insurance premiums& out-of-pocket expenses

MedOne HSAvings

Page 12 of 24

Family Deductible Plan

Your lifetime maximum per covered person is $5 million.

Deductible Amounts Coinsurance AmountsNetwork Non-network Network Non-network

$ 2,500 $ 5,000

$ 3,000 $ 6,000

$ 4,000 $ 8,000

$ 5,000 $10,000

$ 5,500 $11,000 100% 70% of $10,000

$ 6,000 $12,000

$ 7,500 $15,000

$10,000 $20,000

Network Non-network Network Non-network80% of 60% of

$ 2,500 $ 5,000 $ 10,000 $ 10,000$ 20,000 $ 20,000$ 30,000 $ 30,000

$ 3,000 $ 6,000 $ 10,000 $ 10,000$ 20,000 $ 20,000$ 30,000 $ 30,000

$ 4,000 $ 8,000 $ 10,000 $ 10,000$ 20,000 $ 20,000$ 30,000 $ 30,000

$ 5,000 $10,000 $ 10,000 $ 10,000$ 20,000 $ 20,000

$ 5,500 $11,000 $ 10,000 $ 10,000$ 20,000 $ 20,000

$ 6,000 $12,000 $ 10,000 $ 10,000$ 20,000 $ 20,000

$ 7,500 $15,000 $ 10,000 $ 10,000


$ 2,500 $ 5,000 $ 5,000 $ 10,000$ 10,000 $ 20,000$ 15,000 $ 30,000

$ 3,000 $ 6,000 $ 5,000 $ 10,000$ 10,000 $ 20,000

$ 4,000 $ 8,000 $ 5,000 $ 10,000$ 10,000 $ 20,000

$ 5,000 $10,000 $ 5,000 $ 10,000$ 10,000 $ 20,000

$ 5,500 $11,000 $ 5,000 $ 10,000

$ 6,000 $12,000 $ 5,000 $ 10,000

$ 7,500 $15,000 $ 5,000 $ 10,000

To determine your out-of-pocket maximum,add your deductible to your coinsurance portion.

Choosing a MedOneHSAvings Plan DesignMedOne HSAvings providesyou with the possibility oftax savings when pairedwith a health savingsaccount (HSA).

1. Carefully review each ofthe MedOne HSAvingsplan designs listed (family options on page12 and individualoptions on page 13).Choose either the 100%,80%, or 50% option.

2. After you select yourplan design, choose anetwork deductibleamount, then a networkcoinsurance amount.

3. Select an optional benefitsuch as dental insuranceor prescription drug coverage to enhance yourplan. See page 14 for moreinformation.

Family AggregateDeductible

Eligible expenses for all family

members contribute to meeting

the family deductible. When

the family deductible is met

by any combination of family

members, the insurance plan

pays benefits for the entire

family.

100%

Opt

ion

80%

Opt

ion

50%

Opt

ion


Note: The Classic Family plan (Non-PPO) is available.

Med

One

HSA

ving

sSM

MedOne HSAvings

Page 13 of 24

Individual Deductible Plan

Your lifetime maximum per covered person is $5 million.

Deductible Amounts Coinsurance AmountsNetwork Non-network Network Non-network

$ 1,500 $ 3,000

$ 2,000 $ 4,000

$ 2,500 $ 5,000

$ 2,800 $ 5,600

$ 3,000 $ 6,000 100% 70% of $10,000

$ 3,500 $ 7,000

$ 4,000 $ 8,000

$ 5,000 $ 10,000


$ 1,500 $ 3,000 $ 5,000 $ 5,000$ 10,000 $ 10,000$ 15,000 $ 15,000

$ 2,000 $ 4,000 $ 5,000 $ 5,000$ 10,000 $ 10,000$ 15,000 $ 15,000

$ 2,500 $ 5,000 $ 5,000 $ 5,000$ 10,000 $ 10,000

$ 2,800 $ 5,600 $ 5,000 $ 5,000$ 10,000 $ 10,000

$ 3,000 $ 6,000 $ 5,000 $ 5,000$ 10,000 $ 10,000

$ 3,500 $ 7,000 $ 5,000 $ 5,000$ 10,000 $ 10,000

$ 4,000 $ 8,000 $ 5,000 $ 5,000


$ 1,500 $ 3,000 $ 5,000 $ 10,000

$ 2,000 $ 4,000 $ 5,000 $ 10,000

$ 2,500 $ 5,000 $ 5,000 $ 10,000

$ 2,800 $ 5,600 $ 5,000 $ 10,000

To determine your out-of-pocket maximum, add your deductible to your coinsurance portion.

100%

Opt

ion

80%

Opt

ion

50%

Opt

ion


Note: The Classic Individual plan (Non-PPO) is available.

Physician ServicesProfessional feesInpatient and outpatient servicesEmergency room services

Wellness (Routine) Benefit(Eligible only when received from a networkprovider unless otherwise mandated)

Physical examsPap smearsProstate screeningMammogramsLab and X-ray

Pathology (lab) and Radiology(X-ray) Tests

DiagnosticMRI and CAT scans

Surgery and Anesthesiology FeeInpatient and outpatient

Hospital and Facility ServicesInpatient and outpatient careDiagnostic tests, lab, and X-rayEmergency room and urgent care

Complications of Pregnancy

Transplants

AmbulanceGround and air transportation

Skilled Nursing Care30 days per calendar year

Home Health Care20 visits per calendar year

All eligible services aresubject to deductible,then coinsurance to the out-of-pocket maximum, then 100%.

Covered Expenses Apply to Both Family and Individual Deductible Plans

Individual and FamilyWellness

This option pays 100% to

$300 per covered person, per

calendar year. See page 14

for complete details.

Optional Benefits

The following optional benefits, which were discussed on the previous grid pages, are available at an additional cost.

XL (X-ray and Lab) Option (MedOne Plus)The XL Option pays 100% up to $150 per covered person, per calendar year for PPO routine and non-routine x-rays and laboratory tests. Eligible x-ray and lab charges in excess of the XL benefit arecovered subject to your selected deductible and coinsurance, then 100%. This benefit applies to services performed in a physician’s office setting. The XL Option is available when you choose a plandesign with a $30 or $40 office visit copay.

Prescription Drug Coverage Options (MedOne Plus, MedOne Security)The prescription drug coverage options provide benefits for covered expenses including the genericversion of a prescription drug or the brand-name drug if no generic exists. The coverage optionsinclude a separate $0, $500, or $1000 drug prescription deductible then applicable copayment orcoinsurance for covered generic and brand name drugs. (For description of benefits, see chart.)

Prescription Drug Coverage Option (HSAvings)When purchasing the Prescription Drug Coverage Option, your eligible prescription drug expensesapply to your medical deductible and coinsurance limit. When using a member pharmacy youreceive prescription drugs at a reduced cost. You pay the reduced cost at the member pharmacy andthey will either submit the information to us electronically or give you a receipt so you can submitit to us. Prescriptions purchased at a non-member pharmacy are not eligible for a reduced cost.However, eligible charges will apply to your non-network medical deductible and coinsurance whenyou submit your receipt to us. Once the deductible is satisfied for either network or non-network, themedical coinsurance level will cover your prescriptions.

Wellness (Routine) Option (HSAvings)The Wellness (Routine) Option pays 100% up to $300 per covered person, per calendar year for networkroutine physical exams, X-rays and laboratory tests, mammograms, Pap smears, and prostate screenings.Eligible charges in excess of the the Wellness (Routine) Option benefit are subject to normal insuranceplan benefits. This benefit does not apply to services received in a hospital setting.

This Wellness (Routine) Option is not available with the Classic MedOne HSAvings Plans.

Supplemental Accident BenefitThe Supplemental Accident Benefit (SAB) provides first-dollar coverage for each accidental injury($300 for MedOne Plus and MedOne Security, $500 or $1000 for MedOne HSAvings). SAB benefits arepayable the same whether a network or a non-network provider is seen. Depending on your plandesign, you can choose from a maximum of $300, $500 or $1,000 per occurrence with coveredexpenses payable at 100%, and remaining charges subject to copayments, deductibles, and/orcoinsurance. The initial treatment must be received within 72 hours of the accident or injury, andthe claim for expenses must be received within 90 days of the accident or injury.

Add prescription drug

coverage, x-ray and lab

option, and/or dental

insurance for an extra cost to

enhance your plan.

Page 14 of 24

Choose from the following deductibles; $0, $500 or $1,000, then the following benefits apply:

Retail Mail Order


Optional Dental Insurance for IndividualsCombining the Optional Dental insurance with your MedOne health insurance plan gives you a morecomprehensive coverage package. When elected, Optional Dental replaces the CAREINGTONInternational Discount Dental Program. Optional Dental gives you some of the same coverages asemployer-based dental insurance programs.

Optional Dental coverage is available only at the time a MedOne health insurance plan is applied foror up to 45 days after the application is signed.

Waiting Period Information — Waiting periods apply from the original effective date of OptionalDental coverage. (See chart). Credit for coverage with a prior carrier is not applicable to the waitingperiods. A waiting period is the period of time before the insured is eligible for benefits under thePolicy.

Voluntary Term Life and AD&D InsuranceProtect your family against financial misfortune caused by death or accidental dismemberment by purchasing one of our optional Term Life and AD&D Insurance benefit levels — to $300,000 ofcoverage is available (subject to underwriting approval).

Voluntary Dependent Term Life InsuranceThis Dependent Term Life Insurance option provides additional security in case of the death of afamily member (spouse, child age 14 days to 19 years, or a child who’s a full-time student until age25). Dependent Term Life coverages are available only to dependent family members covered on thehealth insurance plan. (See chart).

Page 15 of 24

Optional Dental Services Coverage Waiting Period

Calendar Year Deductible $50 per person N/A(3 per family maximum)

Calendar Year Maximum $750 per person N/A

Preventive 80% of eligible expenses NoOral evaluations and cleanings (twice per (after deductible) waiting periodcalendar year). Topical fluoride treatments (for dependent children to age 16).

Basic Services 60% of eligible expenses 6-monthX-rays; sealants for dependent children (after deductible) waiting period(to age 16); nonsurgical extractions; simple restorative services; stainless steel crowns on primary teeth; repair of crowns, inlays,bridgework, or dentures.

Major Services 50% of eligible expenses 18-monthEndodontics; periodontics; crowns, inlays, onlays, and (after deductible) waiting periodveneers; oral surgery; dentures, bridges, and partials.

Voluntary Dependent Term Life Amounts

Spouse Age/Amount Chart:

Age Amount

0-40 $7,500

41-50 $6,000

51-55 $4,500

56-60 $3,000

61-64 $1,500

65+ None

Dependent Child: $5,000 for each covered dependent child age 14 days to 19years, or if a full-time student, until age 25.

Covered Expenses

Benefits are subject to applicable copayment, deductible, coinsurance, and maximum allowablecharges. All benefits for services are subject to Policy provisions.

Physician Visit ChargesCovered services include physician office visits.

Other Medical Professional ChargesCovered services include physician hospital visits; non-routine injections and injectable drugs; andphysical, respiratory, and occupational therapy.

Wellness BenefitWhen received from a network provider, the following routine services are available to each coveredperson:

• Routine physical exam

• Routine lab tests

• Prostate screening (PSA)

• Pap smear

• Mammogram

Services are not covered when using a Classic Benefit Plan or if they are being done for employment,school, travel, buying insurance, marriage, or family planning.

Other Covered ExpensesCovered services include radiology and pathology tests and prescription drug benefits (if aPrescription Drug Coverage option is purchased).

Surgery and Anesthesiology ChargesCovered services include surgery, anesthesiology, post-operative care, and oral surgery performed ina physician’s office or in a hospital as an inpatient or outpatient.

Vision ExamCoverage includes one comprehensive eye exam every 12 months including refraction. Benefits arepayable at 100% after a $10 copay when services are received from a vision benefit network provider.

Benefits are payable to a maximum of $38 after a $10 copay when services are rendered by a visionbenefit non-network provider.

Note: The vision benefit network is separate from the medical network if a PPO insurance plan is chosen.

Hospital and Other Facility Charges Covered services include semi-private room and board, intensive care, and other facility charges,such as inpatient and outpatient care and emergency room fees.

Complications of PregnancyComplications of pregnancy are covered the same as any sickness for any insured female.Complications do not include expense for normal pregnancy and childbirth.

NewbornsCoverage is included for a newborn or sick baby for 31 days from birth. It includes surgery and treatmentof injury, sickness, birth defects, and medically necessary treatment for cleft lip and cleft palate. Tocontinue coverage, an application form must be received by AMS within 31 days from the date ofbirth. An additional premium may be required.

Home Health CareCovered services include part-time physical, respiratory, occupational, and speech therapy and part-time or intermittent skilled home care and health aide services. Covered to 20 visits per calendar year.

Page 16 of 24

MaximumAllowable Charge

We use a number of national

standards to determine

maximum amounts payable

for medical services. If charges

from a non-network provider

are above these maximum

amounts, the insured person

may be subject to additional

charges (above copays and

coinsurance).

Skilled Nursing CareIncludes coverage for room, board, routine services, and skilled nursing care for 30 days per calendar year.

Hospice CarePart-time nursing care and home health aide services are included up to eight hours a day. Physicaltherapy, services, supplies, prescription drugs, and case management are also included.

TransplantsWhen using the Transplant Provider Network, eligible services are covered at 100% after a $5,000copay per transplant (or your deductible for MedOne HSAvings) to a $1 million lifetime maximum.Outside the Transplant Provider Network, eligible services are covered at 70% after a $10,000 copayper transplant (or your deductible for MedOne HSAvings) to a lifetime maximum of $250,000.Transplant benefits are combined to a total maximum of $1,000,000 per lifetime, per insured.(Copays do not track to the insurance plan’s total out-of-pocket maximum.)

When the covered transplant patient travels more than 100 miles from home to use the TransplantProvider Network, the insurance plan provides a $5,000 lifetime maximum per insured travel benefit. This lifetime maximum covers travel, food, and lodging for the patient and one companion(not available with MedOne HSAvings).

Covered services include the transplant of kidney, liver, pancreas, heart, lung, kidney/pancreas,heart/lung, allogenic bone marrow, autologous bone marrow, stem cell, and donor expenses asdefined in the Policy. Subject to prior approval. Artificial organs are not covered.

Note: The transplant provider network is separate from the medical network if a PPO insurance plan is chosen.

State Coverages — Florida

Sick BabyIn addition to Newborn Coverage referenced on page 16, covered expenses include transportation toand from the nearest facility available to treat a newborn’s condition, to $1,000. Coverage for a newbornof a covered dependent child terminates 18 months after birth.

Mammography ScreeningBenefits are included for covered females age 35 and over, subject to a limited schedule. Also, coverage is included for one or more mammograms per year for females at risk of breast cancer.

Cleft Lip/Cleft PalateCoverage is included for dependent children under the age of 18, for medical and dental treatment,speech therapy, audiology, and nutrition services.

Anesthesia & Hospital for Dental CareCoverage for dental anesthesia is provided for dependent children under age 8, who require dentaltreatment in a hospital or ambulatory surgical center due to a complex dental condition ordevelopmental disability, or the person has one or more medical conditions that would create undorisk, in the course of dental treatment.

Mastectomy & Related ServicesCoverage is provided for both inpatient & outpatient mastectomies. Coverage includes prostheticdevices, breast reconstructive surgery and routine follow-up care.

Manipulative TherapyCovered the same as any sickness.

Page 17 of 24

Temporomandibular Joint Dysfunction (TMJ)Covered the same as any other joint disorder subject to plan provisions.

Extended BenefitsIf group coverage terminates, benefits for disabling conditions are extended to the earlier of 12months or until the maximum benefit is paid. This extension also applies to supplemental accidentbenefits. It does not apply to any other optional benefits.

Child Health Supervision ServicesCovered services for child health supervision services for covered dependent children from themoment of birth to age 16 include: physician delivered or physician supervised services whichinclude a history, physical exam, developmental assessment, anticipatory guidance, appropriateimmunizations and lab tests. There is a maximum of 18 visits per child at specified ages. Benefits arelimited to one visit payable to one provider for all services provided at each visit. Services are notsubject to deductible or copayment but are subject to coinsurance provisions.

OsteoporosisOsteoporosis screening, diagnosis, treatment and management are covered the same as any othersickness.

Pap SmearsBenefits include cervical cancer screening same as any other sickness.

Billing Options

With all MedOne insurance plans, you have the option of annual, semiannual, or quarterly directbilling. Monthly and other mode of payments can be made by automatic bank draft withdrawals orlist billing. Credit cards (VISA® or MasterCard®) will also be accepted for the first month premium only.

Maximum Allowable Charge

We use a number of national standards to determine maximum amounts payable for medical services. If charges from a non-network provider are above these maximum amounts, the insuredperson may be subject to additional charges (above copays and coinsurance).

Out-Of-Pocket Maximum (MedOne Plus, MedOne Security)

The out-of-pocket maximum is a specific limit on the amount of covered expenses you pay per calendar year. When an individual out-of-pocket maximum level has been reached, you no longerpay deductible or coinsurance for that individual for the remainder of that calendar year. The family out-of-pocket maximum is twice the individual amount.

To reach a family deductible maximum, two members of your family must each meet an individualdeductible. Once the family out-of-pocket maximum is met, no additional deductible or coinsurancewill be taken for any family member for the remainder of that calendar year.

Non-network deductibles and coinsurance amounts credit toward both the network and non-networkout-of-pocket maximums. The network deductible and coinsurance apply only to the networkout-of-pocket maximum. Copays do not apply toward out-of-pocket maximums and are collectedbefore and after the out-of-pocket maximums have been met.

Page 18 of 24

Out-Of-Pocket Maximum (MedOne HSAvings)*

The out-of-pocket maximum is a specific limit on the amount of covered expenses you pay per calendaryear. When an individual out-of-pocket maximum level has been reached, that individual no longerpays deductible or coinsurance for the remainder of that calendar year. Out-of-pocket expenses for allfamily members contribute to meeting the family out-of-pocket maximum. Once the family out-of-pocketmaximum has been met, none of the family members pay deductible or coinsurance for the remainderof that calendar year.

Non-network deductibles and coinsurance amounts credit toward both the network and non-networkout-of-pocket maximums. The network deductible and coinsurance apply only to the networkout-of-pocket maximum.

* This insurance plan’s deductible and out-of-pocket levels are intended to satisfy government rules applicable toHDHPs. The rules may change annually. Deductible and out-of-pocket levels may be adjusted at the beginningof each year to stay within these rules. We’ll notify you of any changes as soon as reasonably possible.

Insurance Plan Provisions

Pre-existing Condition LimitationAll medical insurance plans include a pre-existing condition limitation.

A pre-existing condition means (1) a condition for which a person received medical care, treatment,services, medication, diagnosis, or consultation 12 months before the insured person’s effective dateof coverage or (2) a condition that produced symptoms that are distinct and significant enough toestablish the onset of a condition or that the condition manifested itself, where a person learned inmedicine would be able to diagnose the condition because of those symptoms, or where the symptoms would cause an ordinarily prudent person to seek diagnosis or treatment. Pre-existingconditions are covered after a period of 12 months, during which time the person has been continuously covered under the Policy.

We will waive the pre-existing limitation for conditions that are fully and completely disclosed on theapplication; however, we may place an exclusion or impairment rider on a certain condition(s).

Rating and RenewabilityPremium rates are calculated based on a variety of factors. As allowed by state law, these factors mayinclude geographic location, provider network, distribution channels, selected benefits, age, gender,tobacco use, classes, health status of you and your insured dependents, the length of time you areinsured under the insurance plan, health status of the entire pool of insureds in which you areincluded, administrative costs, and other factors. Your initial premium rates are guaranteed for thefirst 12 months of coverage providing you maintain residence in the same geographic location.Thereafter, we reserve the right to periodically adjust the premium rates charged for your coverageunder the Policy. We will provide you with advance written notice a minimum of 30 days prior to theeffective date of a premium change, unless state law requires additional notice.

Premiums may also change on the next premium due after the date when:

• You or your insured dependent attain a higher age;

• A dependent is added to or terminated from the insurance plan; or

• Any benefit is changed, including but not limited to, increases or decreases in a benefit, orthe addition or removal of a benefit from the insurance plan.

If a premium change is for one of the reasons stated above, we will notify you as soon as possibleabout the change. If we find that premiums are incorrect, we will:

• Make a refund to you for any amount of overpaid premiums; or

• Request payment from you for any amount of underpaid premiums.

Page 19 of 24

We reserve the right to adjust administrative and/or service fees. We will notify you prior to anychange. Coverage is guaranteed renewable except when:

• Premium was due and not paid.

• We determine fraud or material misrepresentation under the terms of the contract.

• We do not renew all insurance plans with the same type and level of benefits in the state.

• We no longer sell similar health coverage in a given state.

• You or your dependents no longer reside in the network service area, if covered by a networkinsurance plan.

• You move to a state where, by law, we are not licensed to do business.

• The group Policy terminates.

You may terminate insurance at any time by providing us written notice prior to the requested termination date. The termination date will be the first of the month. Insurance will terminate at12:01 a.m. Central Standard Time on the termination date.

Health Insurance Portability and Accountability Act of 1996 (HIPAA)The Health Insurance Portability and Accountability Act (HIPAA) requires various changes to individualhealth insurance plans. In some states, the insurer must guarantee issue such insurance plans to eligiblepersons who lose coverage under a prior group health plan. Such persons are not required to satisfyanother pre-existing condition limitation. The new insurer may require copies of a Certificate ofCreditable Coverage to determine how to apply the pre-existing condition limitation. Eligible individualsare guarantee issue to selected health plans.

An eligible individual means a person who meets all of the following requirements:

• Has a total of 18 of more months of continuous creditable coverage, with less than a 63-daybreak from the most recent coverage.

• Most recent coverage was under a group plan, governmental plan, church plan; or the mostrecent creditable coverage was under an individual plan that terminated because the insurerbecame insolvent, the insurer discontinued offering all individual coverage in Florida, or fora network plan, the insured no longer lives in the Florida service area of the insurer.

• Has elected continuation coverage under COBRA or a similar state program, and has exhaustedor will soon exhaust this coverage.

• Was not terminated for nonpayment of premiums, fraud, or intentional misrepresentationof material fact.

• Is not eligible for coverage under a group plan, health conversion policy, Medicare, orMedicaid; and does not have other health insurance coverage.

Creditable coverage includes health insurance coverage and other health coverage, such as coverageunder other group health plans, short-term medical coverage, Medicaid, Medicare, military-sponsoredhealth care, and similar plans. Creditable coverage does not include accident-only coverage, long-termcare coverage, liability or workers’ compensation insurance, automobile medical payment insurance,or other similar insurance.

Reinstatement of CoverageIf your coverage has lapsed for nonpayment of premium, you may be able to apply for reinstatementof coverage (not available in all states). If your coverage lapses and reinstatement is available in yourstate, you’ll receive information about how the process works. Reinstatement is not guaranteed.

Page 20 of 24

Excess/Subrogation/Right of Reimbursement

We do not pay benefits when other insurance also pays for the same medical expenses. We subrogateto the extent of our payment when a party causes or is liable to pay for our insured party’s injury orsickness. Insureds are required to repay us from any settlement, judgment, or any other paymentreceived from any other source.

Precertification Penalty

Certain procedures that you or your doctor do not precertify with us are subject to a penalty of 10%of covered eligible charges to a maximum of $1,000 per confinement, procedure, or occurrence.

Limitation and Exclusions

Please read carefully.MedicalNo medical insurance coverage is provided for any of the following unless specified elsewhere as acovered benefit for:

Alcoholism, drug abuse, mental or nervous disorders • Any treatment or supply for hair loss or growth• Any weight loss method • Attempted suicide or intentional self-inflicted injury or sickness whilesane or insane • Blood products replaced by donation or blood storage except for scheduled surgery• Bony protuberances or misalignment of forefoot and toes including bunions, spurs, and hammertoe• Care provided by a family member or by a person residing with you • Cesarean-section delivery • Civilor criminal battery or felony • Cost of brand-name drugs in excess of the cost of generic drugs • Costto rent durable medical equipment that exceeds the cost to purchase the item • Custodial care • Dentalsurgery except as defined under the Policy • Dental treatment from chewing injury or dental implants• Drugs obtainable without a written prescription • Emergency room treatment if no emergencyexists • Exams, x-rays, and tests for routine physicals when using a non-network provider or if exams,x-rays, and tests are being done for employment, school, travel, buying insurance, marriage, or familyplanning • Expense for which no benefit is described • Experimental or investigative procedures,devices, or drugs • Eye exams, eyeglasses, contact lenses, or surgery to improve eyesight • Hearingaids or exams • Hospital costs for admission from 8 a.m. Friday to midnight Sunday except for anemergency or scheduled surgery • Immunizations except for childern to age 16 • Items used only forcomfort such as a humidifier • Learning disabilities or developmental disorders, testing or trainingfor education or vocation, vision therapy, or speech therapy except for injury or functional defect •Marriage, family, or sex counseling • Multiple surgeries done at the same time; secondary proceduresare covered up to one-half the cost of each additional procedure • Normal pregnancy • On-the-jobinjury or sickness for you and your spouse unless enrolled and approved by us for the On-the-JobProtection Benefit • Plastic or cosmetic surgery unless for reconstruction caused by a covered injury,sickness, or mastectomy only when the injury or sickness occurred while insured under the policy• Pre-admission testing in a hospital not done within seven days before scheduled admission •Pre-existing conditions • Prescription drug charges except in hospital or hospice, unless the prescriptiondrug rider is purchased • Private duty nursing • Riot • Routine injection of drugs • Sclerotherapy forvaricose veins • Services and supplies furnished by a government plan, hospital, or institution unlessby law you must pay • Services and supplies not medically necessary, not recommended or approvedby a doctor, or not provided within the scope of a doctor’s license • Services or supplies charged inexcess of the maximum allowable charge • Services or supplies provided by your employer or providedafter insurance terminates • Services or supplies provided free of charge • Sex change operations andcomplications; testing and treatment for impotency or infertility; any treatment, procedure, drug, ordevice to prevent or promote conception • Skilled nursing facility confinement beyond 30 days percalendar year • Sterilization • Strained or flat feet; instability or imbalance of feet or ankles; orthopedicshoes or supplies; cutting or removal of corns, calluses, or toenails except for diabetes or similar disease• Treatment of the following conditions during the first six months you are insured by the Policy:hemorrhoids, hernia, tonsillectomy or adenoidectomy (except covered for an emergency), and varicoseveins • Treatment outside of the U.S. except for an emergency • War or military service • Well baby care.

Page 21 of 24

DentalThe following dental expenses are not covered:

Any dental supplies including, but not limited to take-home fluoride, prescription drugs andnonprescription drugs • Any dental procedures for which benefits are payable under the medicalinsurance provision of the certificate • Athletic mouth guards • Attempted suicide or intentionallyself-inflicted injury while sane or insane • Broken appointments • Changing vertical dimension,restoring occlusion, bite registration, or bite analysis • Charges for dental services that are notdocumented in the dentist’s records • Correcting congenital malformation • Cosmetic procedures • Costto complete claim forms • Dental implants and related services • Dental treatment, appliance, ordevice related to periodontal splinting, correction of abrasion, erosion, attrition, abfraction, bruxism, ordesensitizing or teeth that can be restored by other means • Diagnostic casts • Due to your participationin a riot or committing a felony • Duplicate dentures • Engaging in an illegal occupation • Expensesincurred during a waiting period • For services incurred prior to you and your covered dependent’seffective date under the Policy • Gold foil restorations • Harmful habit appliances • Hospital and relatedanesthesia charges • Initial placement of full or partial dentures, or bridges, to replace natural teethlost before the effective date of insurance • Lab procedures • Local anesthesia • Occurring during orarising from your course of occupation or employment • Occlusal guards • Oral hygiene instruction• Orthodontia • Orthognathic surgery • Participating in a professional or semi-professional contestfor compensation, wage or salary • Photographs • Plaque control • Precision or semi-precisionattachments • Procedures that do not satisfy the definition of Covered Expenses, not dentally necessary,not rendered or not rendered within the scope of the dentist’s license • Procedures that cost in excessof the maximum allowable charge • Provided by a government plan or educational institution asallowed by law • Removal of sound functional restorations; temporary crowns and temporaryprosthetics • Replacement of bridges, crowns, inlays, onlays, or veneers within seven years of the lastreplacement, except for loss of natural tooth • Replacement of bridges, crowns, dentures, inlays,onlays, or veneers if they can be repaired or restored • Replacement of full or partial dentures withinfive years of the last replacement, except for loss of natural tooth • Replacement of lost or stolenappliances or retainers • Services not incurred by the insurance termination date • Services paid byworkers’ compensation • Services received outside the U.S. except for emergency treatment for pain• Services rendered by a family member or someone who lives with you or provided free withoutinsurance • Sterilization fees • Teeth that are not periodontally sound or have a questionable prognosisas determined by us • Thermonuclear or atomic explosion or resulting exposure to radiation • Treatmentof fractures, cysts • Treatment of halitosis and any related procedures • War or military service.

VisionAny eye examination, or any corrective eyewear, required by an employer as a condition of employment •Corrective surgical procedures such as, but not limited to, Radial Keratotomy, Photo-refractive Keratectomyand corneal modulation • Corrective vision treatment of an experimental or investigative nature • Medicalor surgical treatment of the eyes • Orthoptics or vision therapy training and any associated supplementaltesting.

Accidental Death & DismembermentNo accidental death and dismemberment benefit is payable for loss resulting from:

Air travel or flight except as fare-paying passenger • Committing or attempting to commit civil orcriminal battery or felony • Driving while legally intoxicated or while using non-prescribed drugs• On-the-job injury or sickness • Participating in a riot • Sickness unless a direct result of coveredinjury or from accidental ingestion of a contaminated substance • Suicide or intentional self-inflictedinjury or sickness • Voluntary taking of sedative, drug, or inhaling gas unless prescribed or administeredby a doctor • War or military service.

Page 22 of 24

BR-0512-12-1-00 12/05 Page 24 of 24

(800) 232-5432 • www.eAMS.com

Insurance products are underwritten by American Medical Security Life Insurance Company, a whollyowned subsidiary of PacifiCare Health Systems, Inc. AMS and PacifiCare Health Systems, Inc. are not responsible

for each others financial condition or contractual obligations.

This is an outline only and not intended to serve as a legal interpretation of benefits. Reasonable effort has beenmade to have this outline represent the intent of contract language. However, the contract language standsalone and the complete terms of the coverage will be determined by the Group Policy TNI1000. Applicable lawwill apply with respect to pre-existing condition limitations, eligibility, rating, and renewability.

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